Lateral and Medial Epicondylitis Ian S Rice MD

Lateral and Medial Epicondylitis Ian S Rice MD Sports Medicine Orthopedic Surgeon

Outline • Epidemiology • Anatomy • Biomechanics • Pathophysiology • Diagnosis • Treatment • Research

Lateral Epicondylitis Tennis Elbow

History • First described in 1873 by Runge • Tendinosis not inflammatory condition • Affects common attachment of extensor muscles of forearm to lateral epicondyle of humerus Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64 Van Hofwegen, C. , et al. (2010) Clin Sports Med 29: 577 -97

Epidemiology • Incidence 1%-3% adults per year in UK • 10 -50% of people who play tennis regularly, Male > Female • Lateral 4 -7 times more common than Medial • 35 – 55 years of age • Male = Female in general population • Dominant arm > Non-dominant Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64 Van Hofwegen, C. , et al. (2010) Clin Sports Med 29: 577 -97

Anatomy • Common Extensors: • Extensor Carpi Radialis Brevis* • Extensor Carpi Radialis Longus • Extensor Digitorum • Extensor Carpi Ulnaris • Radial superficial sensory + deep PIN Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64 Van Hofwegen, C. , et al. (2010) Clin Sports Med 29: 577 -97

Anatomy • Radial Collateral Ligament • Lateral Ulnar Collateral Ligament • Annular Ligament

Biomechanics: Extensor Group • Eccentric contraction of ECRB • Excessive/repetitive use extensors or supinator • Tennis, typing, piano, manual work • Risk factors in racquet sports: • • • Incorrect technique Extended duration of play Frequency of play Size of handle Racquet weight Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Pathophysiology • Paucity of inflammatory cells • Gross: Grayish, homogenous, edematous and friable tissue • Tendinosis degenerative process • Rate of stretching exceeds tolerance microtears tendinosis Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64 Van Hofwegen, C. , et al. (2010) Clin Sports Med 29: 577 -97

Histologic Stages of Microtrauma • • 1: Acute inflammatory response • Sometimes resolves 2: Angiofibroblastic hyperplasia (increased concentration of fibroblasts, vascular hyperplasia, disorganized collagen) • • Hypercellularity in both organized and unorganized fasion Most common stage of presentation for treatment 3: Structural failure of tendon with partial of complete rupture 4: Features of stage 2 or 3 plus fibrosis, soft calcification within collagen and hard osseous calcification Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Pathophysiology: Microscopy Normal Tendon Kraushaar, BS, et al. (1999) J Bone Joint Surg. 81 A(2): 1158 -64

Pathophysiology: Microscopy Tendinosis of ECRB with some normal tendon and some disorganized tendon Kraushaar, BS, et al. (1999) J Bone Joint Surg. 81 A(2): 1158 -64

Pathophysiology: Microscopy Angiofibroblastic hyperplasia meets normal tendon Kraushaar, BS, et al. (1999) J Bone Joint Surg. 81 A(2): 1158 -64

Pathophysiology: Other Theories • • • Stress shielding certain sections of tendon leading to structural weakening Shear forces leading to fibrocartilaginous composition of ECRB attachment weak attachment tendinosis Long muscle contraction rendering tendon avascular free radicals Hyperthermic injury Protein kinase apoptosis Altered gene expression and imbalance of matrix metalloproteinases and growth factors Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Pathophysiology: Neurologic Changes • High variability of patient’s symptoms • Increased concentration neurotransmitters (glutamate), which sensitize pain response and direct irritation by lactate • Cascade of changes in PNS neurons, which leads to sensitization of CNS • May explain associated neck pain in 56% of patients • Could be other overuse or altered biomechanics Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Diagnosis: History • Pain at lateral epicondyle • • Radiates down extensor mass, occasionally proximally Exacerbated by contraction of extensor mass • Insidious onset • History of repetitive activity or overuse • Inability to hold items Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Diagnosis: Physical Examination • Tenderness ECRB origin or more diffuse centered about lateral epicondyle • Resisted extension • Full elbow/wrist ROM • Sensation normal • Wrist Extensor weakness 2º pain • Decreased grip strength Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Differential Diagnosis • Cervical radiculopathy • Elbow overuse compensating for frozen shoulder • PIN entrapment • Radiocapitellar degenerative changes or OCD • Inflammation of anconeus • Infection Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Diagnosis: Imaging • Plain film: 22%-25% calcification within soft tissue • Otherwise normal Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Diagnosis: Imaging • MRI: Presence of degenerative tissue, tears in tendon • • More reproducible than US Intra-articular pathology Poor correlation with symptoms Generally not necessary • Clinical diagnosis Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Treatment: Nonsurgical • 80% + Improve within 1 year • Relative rest • Ice • NSAIDs • Steroid Injection: Short-term relief • Counterforce Bracing (decrease tension on extensors) and wrist splint • PT/Rehab: range of motion, eccentric strengthening Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Treatment: Alternative • Ultrasound/Extracorporeal shock waves (ECSW’s) • Acupuncture/dry needling • Platelet-rich plasma: growth factors Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64

Treatment: Surgical • 4%-11% require surgery • Extra-articular extensor tendon debridement • Intra-articular: excise synovial fringe and portion of orbicular ligament • Tendon excision with origin reattachment

Surgical: Open Debridement • 8 -10 cm incision over lateral epicondyle • Subperiosteal detachment of common tendon • Tendon debridement • Decortication of epicondyle with rongeur • Drill 2 v-shaped tunnels with horizontal mattress reattachment • Splint 7 -10 days with progressive mobilization

Surgical: Open Limited Incision Ahmed, Z. , et al. (2013) Bone Joint J. 95 -B: 1158 -64 Van Hofwegen, C. , et al. (2010) Clin Sports Med 29: 577 -97

• 60 patients • Randomized to injection with PRP, steroid or saline • Neither PRP no steroid superior to saline • • Pain at 3 months Steroid decreased pain at 1 month, hypervascularity, and tendon thickness

• 165 patients • Randomized to 1. steroid injection, 2. placebo injection, 3. steroid plus therapy, 4. placebo plus therapy • Steroid injection worse than placebo • Therapy did no change outcome JAMA 2013

PRP vers Placebo • PRP versus placebo (AJSM 2013) • • • No change 12 weeks PRP improved 24 weeks Pain

Medial Epicondylitis Golfer’s Elbow

Epidemiology • Prevalence <1% • 3. 8 – 8. 2% occupational settings • 10 -20% of epicondylitis patients Nirav, HA, et al. (2015) JAAOS. 23. 6: 348 -55

Anatomy • Pronator Teres* • Flexor Carpi Radialis • Palmaris Longus • Flexor Digitorum Superficialis • Flexor Carpi Ulnaris • Medial Collateral Ligament Nirav, HA, et al. (2015) JAAOS. 23. 6: 348 -55

Anatomy Common flexor tendon attaches to medial humeral epicondyle anteriolrly and attaches proximally to anterior bundle of ulnar collateral ligament, becomes confluent with hyperplastic section of anteromedial joint capsule Nirav, HA, et al. (2015) JAAOS. 23. 6: 348 -55

Biomechanics • Repetitive eccentric loading • Wrist flexion, forearm pronation • Valgus stress at elbow Nirav, HA, et al. (2015) JAAOS. 23. 6: 348 -55

Pathophysiology • Peritendinous inflammation • Angiofibroblastic hyperplasia • Irreparable fibrosis or calcification • Ulnar collateral ligament Nirav, HA, et al. (2015) JAAOS. 23. 6: 348 -55

History • Sports: overhead throwing, golf, tennis, football, weightlifting, bowling • Occupational • • Forceful grip Loads >44 lbs Constant vibratory force at elbow 84% have concomitant work-related disorder • Carpal tunnel, lateral epicondylitis, rotator cuff tendinitis Nirav, HA, et al. (2015) JAAOS. 23. 6: 348 -55

Diagnosis • Pain along medial elbow • Radiation to proximal forearm • Increased pain with resisted pronation and wrist flexion • Tenderness 5 -10 mm distal and anterior to epicondyle • Normal ROM • Normal Sensation • Resisted wrist flexion, forearm pronation, grip may be weak • Valgus Stress Ligamentous pain • X-rays usually normal • Concomitant ulnar neuritis Nirav, HA, et al. (2015) JAAOS. 23. 6: 348 -55

Imaging MRI is standard of care when imaging needed Nirav, HA, et al. (2015) JAAOS. 23. 6: 348 -55

Treatment: Non-surgical • Similar to Lateral Epicondylitis • Rest • 6 -12 weeks off throwing • NSAIDs • Wrist flexor and forearm pronator stretching • Night splinting • Therapy: ROM, eccentric strengthening Nirav, HA, et al. (2015) JAAOS. 23. 6: 348 -55

Treatment: Surgical Nirav, HA, et al. (2015) JAAOS. 23. 6: 348 -55

Research • No RCT in last 3 years